Surgical instrument with multiple rotatably mounted offset end effectors

ABSTRACT

An instrument for operating on anatomical tissue includes a barrel having two or more drivers therein which can be manipulated from a proximal end of the barrel. End effectors of each driver are offset from a rotatable shaft by a transverse arm. In an insertion position, the end effectors are confined within the diametrical dimension of the barrel at a distal end thereof. After insertion, the end effectors can be manipulated to extend beyond the diametrical dimension of the barrel to provide a large working span for manipulating tissue or performing other procedures on tissue.

RELATED PATENT APPLICATION DATA

This application is related to applicant's copending applications Ser.No. 08/366,285 filed on Dec. 29, 1994, now U.S. Pat. No. 5,665,109, Ser.No. 08/377,723 filed on Jan. 25, 1995, now U.S. Pat. No. 5,643,295, Ser.No. 08/401,002 filed Mar. 9, 1995, now U.S. Pat. No. 5,695,505, Ser. No.08/585,875 filed Jan. 16, 1996, now U.S. Pat. No. 5,810,853, Ser. No.08/758,648 filed Nov, 27, 1996, now U.S. Pat. No. 5,759,188, thedisclosures of which are incorporated herein by reference. Also, thisapplication is related to applicant's concurrently filed applicationsentitled "Surgical Instrument with Rotatably Mounted Offset End Effectorand Method of Using the Same", "Suturing Instrument with RotatablyMounted Offset Needle Holder and Method of Using the Same", and"Suturing Instrument with Multiple Rotatably Mounted Offset NeedleHolders and Method of Using the Same", the disclosures of which are alsoincorporated herein by reference.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention pertains to surgical procedures conducted onbodily or anatomical tissue and, more particularly, to an apparatus andmethod for accomplishing various procedures during endoscopic and opensurgery.

2. Discussion of the Related Art

Various steps are accomplished in both open surgery and endoscopicsurgery. Generally the multiple steps require various operatinginstruments, or "end effectors". "Open surgery" refers to surgerywherein the surgeon gains access to the surgical site by a relativelylarge incision and "endoscopic surgery" refers to minimally invasivesurgery wherein the surgeon gains access to the surgical site via one ormore portals through which endoscopes are introduced to view thesurgical site and through which instruments having end effectors, suchas forceps, cutters, needle holders, cauterizers, clip applicators, andthe like, are introduced to the surgical site.

The performance of an endoscopic procedure typically involves creationof one or more puncture sites through a wall of an anatomical cavityusing a penetrating instrument including an obturator, such as a trocar,disposed within a portal sleeve. After the penetrating instrument haspenetrated into the anatomical cavity, the obturator is withdrawnleaving the sleeve in place to form a portal in the cavity wall for theintroduction of instruments such as endoscopes, scissors, forceps,needle holders and the like into the anatomical cavity.

The various end effectors at the distal end of the instrument aremanipulated by the surgeon using controls disposed at the proximal endof the instrument. Of course, it is desirable to move the end effectorsthrough various paths, depending on the step being performed.Traditionally, this was accomplished by moving the entire distal end ofthe endoscopic instrument. However, recently it has been proposed toprovide a plurality of end effectors on a single endoscopic instrumentto minimize the number of puncture sites and thus reduce the risk andhealing time associated with endoscopic surgery. For example, copendingU.S. application Ser. No. 08/758,648 filed Nov. 27, 1996, the disclosureof which is incorporated herein by reference discloses a device havingtwo needle holders for suturing.

When a plurality of end effectors are incorporated into a singleendoscopic device it is often desirable to move the end effectorsindividually with respect to one another without necessarily moving theentire distal end of the device. Also, it is often desirable to move theend effector through a predetermined path, such as an arc or the like,to manipulate tissue without repositioning the entire endoscopic device.

Of course, it is also generally desirable to minimize the size of eachpuncture site. Further, in order to permit operations on a wide range oftissue sizes, it is desirable to provide a wide range of relativemovement between the end effectors. These objectives, minimalnumber/small size punctures and wide range of relative movement, areseemingly contradictory. Conventional devices have not achieved theabove-noted objectives.

U.S. Pat. No. 5,582,617 discloses an endoscopic instrument having an endeffector that can move from a position within the diameter of the barrelof the device to a position outside the diameter. However, this devicemust pivot about an axis that is transverse to the axis of the barreland an axis that is coincident with the axis of the barrel and thusrequires a complex movement and linkage to accomplish the disclosedfunctions. Accordingly, this device falls short of providing an endeffector that can be utilized over a large working span for a wide rangeof applications.

SUMMARY OF THE INVENTION

Accordingly, it is a primary object of the present invention to overcomethe above-mentioned disadvantages of the prior art and to improvesurgical instruments and methods of surgery including endoscopicsurgery.

It is also an object of the invention to increase the working span andminimize the insertion diameter of a surgical instrument.

Yet another object of the present invention is to minimize the number ofpuncture sites required for performing operative steps on anatomicaltissue in an endoscopic or open surgery procedure by inserting more thanone end effector through a single puncture site or incision with aninstrument that is operable to move the end effectors relative to oneanother in a cooperative manner to operate on anatomical tissue.

A first aspect of the present invention is generally characterized in aninstrument for operating on anatomical tissue including a barrel, atleast two shafts extending through the barrel and at least one endeffector mounted on each shaft. The end effectors are offset from theaxis of the shaft by a connecting member to permit the end effector torotate through a path that is outside of the diametrical dimension ofthe barrel. During insertion, the end effectors can be positioned withina diametrical dimension of the device either by rotating the shaft or bydrawing the shaft and the end effectors into the barrel in an axialmanner.

In another aspect of the invention the end effectors are manipulatedrelative to one another in concert to facilitate tissue manipulation,ligating, cutting, clipping cauterizing or similar operations.

Other objects and advantages of the present invention will becomeapparent from the following description of the preferred embodimentstaken in conjunction with the accompanying drawings, wherein like partsin each of the several figures are identified by the same referencenumerals.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A illustrates the suturing instrument of the first preferredembodiment;

FIG. 1B illustrates distal/proximal movement of the driver;

FIG. 2 is a perspective view of the barrel of the first preferredembodiment;

FIG. 3A is a perspective view of the distal end of the first preferredembodiment in the insertion position;

FIG. 3B is an end view of the distal end of the first preferredembodiment in the insertion position;

FIG. 4 is a perspective view of the distal end of the first preferredembodiment in an operative position;

FIG. 5A is a side view of a driver of the first preferred embodiment;

FIG. 5B illustrates an alternative driver;

FIG. 5C illustrates an alternative driver;

FIG. 5D illustrates an alternative driver;

FIG. 6 i s a sectional view of the inner mechanism of the proximalcontrols in an operative position taken along line 6--6 in FIG. 1;

FIG. 7 is a sectional view of the inner mechanism of the proximalcontrols in an adjusting position taken along line 6--6 in FIG. 1;

FIG. 8 is a side view of the distal end of the first preferredembodiment;

FIG. 9 is a perspective view of the distal end of the second preferredembodiment in the insertion position;

FIG. 10 is a perspective view of the distal end of the second preferredembodiment in an operative position;

FIGS. 11A and 11B illustrate a second preferred embodiment;

FIGS. 12A and 12B illustrate a third preferred embodiment;

FIGS. 13A and 13B illustrate a fourth preferred embodiment;

FIGS. 14A and 14B illustrate a fifth preferred embodiment;

FIGS. 15A and 15B illustrate a sixth preferred embodiment;

FIGS. 16A and 16B illustrate a seventh preferred embodiment;

FIGS. 17A and 17B illustrate an eight preferred embodiment;

FIGS. 18A and 18B illustrate a ninth preferred embodiment;

FIGS. 19A and 19B illustrate a tenth preferred embodiment;

FIGS. 20A and 20B illustrate an eleventh preferred embodiment;

FIG. 21 illustrates an alternative arrangement of the proximal controls;

FIG. 22 illustrates another alternative arrangement of the proximalcontrols having only one set of handles;

FIG. 23 illustrates the inner switching mechanism of the proximalcontrols of FIG. 22 in partial section taken along line 23--23;

FIG. 24 illustrates the inner switching mechanism of the proximalcontrols of FIG. 22 in partial section taken along line 23--23;

FIG. 25 illustrates a thirteenth embodiment of the invention having morethan two driver; and

FIG. 26 illustrates the distal end of another alternative driver.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

The instrument of the present invention can be utilized for any type ofanatomical tissue in any type of anatomical cavity. Accordingly, whilethe instrument is described hereinafter for use with a portal sleeve inendoscopic procedures, such as laparoscopy, the instrument can be usedin open surgery and with catheters and other small and large diametertubular or hollow cylindrical members providing access to smallcavities, such as veins and arteries, as well as large cavities, such asthe abdomen.

A surgical instrument according to a first preferred embodiment of thepresent invention is illustrated at 30 in FIG. 1A and includescylindrical barrel, or outer shaft, 32 which has an elongated passagedefined therein, driver 40, and driver 50. Driver 40 and driver 50 aresubstantially contained within cylindrical barrel 32 as is described indetail below.

As shown in FIGS. 1A and 2, barrel 32 terminates distally at a distalend which is disposed within the body cavity of a patient during use andterminates proximally at a proximal end which is disposed externally ofthe patient during use. As shown in FIG. 2, barrel 32 includes aplurality of operating channels 38a-d extending longitudinallytherethrough. Barrel 32 can have additional channels for receiving oneor more additional instruments to be introduced in the abdominal cavityor barrel 32 can have fewer channels as needed. Optical fibers 39 extendthrough barrel 32 to transmit light from a proximal light source to thebody cavity of a patient. Channels 38a-d can be formed by thin wall,tubular sleeves extending longitudinally through barrel 32 or merely byvoid spaces defined by optical fibers 39. FIG. 1B illustrates thatdriver 40 and driver 50 can be movable in proximal and distaldirections.

FIG. 5A illustrates driver 40 removed from barrel 32 for illustrativepurposes. Driver 40 includes elongated, tubular outer member 42 andelongated tubular inner member 44 disposed within outer member 42. Outermember 42 and inner member 24 define a shaft that is rotatable in barrel32. Outer member 42 has a distal end on which two diametrically enlargedflanges 46 are disposed. Flanges 46 serve to fix collar 55, which hascircumferential teeth, on outer member 42 while permitting collar 55 torotate with respect to outer member 42. The function of collar 55 isdescribed in detail below.

FIG. 5B illustrates driver 40 having pivoting jaws 50A and 50B. FIG. 5Cillustrates driver 40 having flexible inner member 44 which can beadvanced distally to grasp a needle or other object disposed in a notchformed in outer member 42. FIG. 5D illustrates driver 40 that isflexible and can be drawn into barrel 32 to be straightened. In a normalstate driver 40 of FIG. 5D is angled.

The end effectors of this embodiment are forceps and are constituted ofjaw members 50A and 50B biased to be normally disposed in an openposition in which there is a gap defined between jaw members 50A and50B. Of course, the inner surfaces of jaw members 50A and 50B can beshaped in any other appropriate way to firmly grasp tissue or otherobjects when jaw members 50A and 50B are in a closed position as shownin FIGS. 3A, 3B, 4, and 5. The end effectors can be of any other typeincluding, but not limited to, cauterizing electrodes, clip applicators,scissors, needles, biopsy devices, or the like.

Driver 40 can be designed in various known ways permitting jaw members50A and 50B to be movable between the closed position and the openposition, such as the configurations disclosed above. Jaw members 50Aand 50B can be biased toward the open position. Arms 51A and 51B serveas connecting members between jaw members 50A and 50B and inner member44 and can be made entirely or partly of resilient, flexible or springmaterials, or materials having shape memory, to be resiliently biasedtoward the open position while being movable to the closed position andback to the open position. Flanges 52A and 52B are respectively formedon arms 51A and 51B. Driver 50 is similar to driver 40 and similarelements thereof are designated with like reference numerals having thesuffix "'". The opening and closing movement of jaw members 50A and 50Bin this preferred embodiment is described below.

As illustrated in FIG. 1A, the proximal controls of the preferredembodiment include two sets of scissor type handles 62 and 64 and 62'and 64', extending from housing 89, that can be pivoted towards oneanother to cause movement of the associated end effector, in thisembodiment jaw members 50A and 50B and jaw members 50A' and 50B',respectively. One set of handles is disposed on one side of barrel 32and the other set of handles is disposed on the other side of barrel 32.The operation of one set of handles 62 and 64 is discussed in detailbelow with respect to driver 40. However, the other set of handlers 62'and 64' operate in connection with driver 50 in a similar manner.

Button 66 is provided proximate an axis of rotation of handles 62 and64. Depressing button 66 disengages handles 62 and 64 from driver 40 andpermits handles 62 and 64 to be rotated in concert about the axis ofrotation as indicated by arrow A in FIG. 1A. This allows the surgeon toorient handles 62 and 64 in a desired manner during surgery. FIGS. 6 and7 illustrate the internal mechanism coupling handles 62 and 64 to driver40 and handles 62' and 64' to driver 50. Operating member 82 isrotatably disposed on shaft 140 and has gear portion 84 that is engagedwith collar 55 on outer member 42 of driver 40. Operating member 82 isfixed axially on shaft 80 and has radially extending serrated teeth 83formed on a side opposite gear portion 84.

Handle 62 is also rotatably mounted on shaft 80 and is slidable relativeto shaft 80. Handle 62 is fixed in axial position by projections 88formed on an inner surface of housing 89. Handle 62 has serrated teeth85 on each side thereof at a top portion that is disposed around shaft80. Shaft 80 is mounted on stem 81 and is normally biased to the rightin FIG. 6 by spring 72 to press serrated teeth 83 into engagement withserrated teeth 85 thus fixing the relative position of operating member82 and handle 62. Handle 64 is rotatably mounted on shaft 80 and fixedaxially on shaft 80. Serrated teeth 87 are formed on each side of handle64 at a top portion that surrounds shaft 80 and serrated teeth 87 arenormally biased by spring 72 into engagement with teeth formed on aninner surface of housing 89 to fix the position of handle 64 withrespect to barrel 34. In this state handle 62 is coupled to outer member42 of driver 40 and handle 64 is fixed in position. Pressing handle 62towards handle 64 will cause outer member 42 to move over flanges 52Aand 52B (see FIG. 5) to close jaws 50A and 50B.

When shaft 80 is pressed to the left in FIG. 6, by depressing button 66,serrated teeth 87 engage serrated teeth 85 to fix the relative positionsof handles 62 and 64 and serrated teeth 83 are disengaged from serratedteeth 85 to disengage handle 62 from driver 40, as illustrated in FIG.7. This permits the set of handles 62 and 64 to be rotated in concert tothe desired orientation. Button 66' is also illustrated as beingdepressed in FIG. 7 to illustrate the motion of the mechanism associatedwith driver 50.

As noted above, cam surfaces 52A and 52B are formed on outer surfaces ofarms 51A and 51B respectively. When handle 62 pressed towards handle 64,outer member 42 moves distally over cam surfaces 52A and 52B causing jawmembers 50A and 50B to move toward one another to the closed position.Cam surfaces 52A and 52B can be formed by bent portions defined in legs51A and 52B or by separate elements that are attached to, or formed on,legs 51A and 51B. Release of handles 62 and 64 causes jaw members 50Aand 50B to return to the open position due to the resilient bias of arms51A and 51B. Lock protrusions 63 and 65 are disposed on handles 62 and64 respectively (see FIG. 1A) and are serrated to interlock and allowthe position of handles 62 and 64 to be maintained in a statecorresponding to a desired position of jaw members 50A and 50B. Lockprotrusions 63 and 65 can be pivoted to a position of which they willnot interlock if desired. Additionally, handles 62 and 64 can be biasedapart or outer member 44 can be biased distally or proximally, dependingon desired operating characteristics.

Driver 50 is constructed similarly to driver 40 and thus furtherdetailed description thereof is omitted. It will be appreciated that thejaw members or other end effector of driver 40 and driver 50 can be ofdifferent configurations dependent upon procedural use and otherconsiderations such as cost. Also, cutting elements 53 can be providedon the jaw members as needed to cut suture material or tissue (see FIG.4). The second set of handles 62' and 64' can be coupled to driver 50 ina similar manner. Accordingly, control of driver 50 is similar to thatof driver 40 and further detailed description is omitted. Also, housing89 and 89' can be positioned along a central transverse axis of barrel32 and can be rotatable. In such a case an offset gear arrangement canbe provided to couple handle 62 to collar 55.

The shafts of driver 40 and driver 50 are disposed in channels 34b and34d respectively to extend through barrel 32 and can be rotated abouttheir respective longitudinal axes relative to barrel 32 by rotatingknob 48 (for driver 40) or knob 48' (for driver 50). Push buttons 61 and63 are respectively provided for unlocking knobs 48 and 48'. Also, arms51A and 51B of needle driver 40 can be positioned to extend beyond arms51A' and 51B' of driver 50, i.e. the transverse portion of the arms arein different planes, as illustrated in FIG. 8, to permit the arms to beplaced in an overlapped crossed position (illustrated in FIGS. 3A and3B). As noted above, driver 40 and driver 50 can be movable proximallyand distally.

Channel 34a and channel 34b can be used as operating channels forsuction devices, irrigation devices, or any other appropriate instrumentsuch as a cautery device or the like. Also, aperture 70 is formed in aposition of arm 51B that is proximal a distal end of inner member 44 todefine an operating channel through driver 40 and aperture 70' is formedin arm 51B' to define an operating channel through driver 50 (See FIG.3B for example).

In use, instrument 30 is inserted into a body cavity using knowntechniques, while driver 40 and driver 50 are in the positionillustrated in FIGS. 3A and 3B. Note that the entire device can beinserted through a single puncture site. Also, in this position, jawmembers 50A and 50B and 50A' and 50B', or any other appropriate endeffectors, are disposed within the diametrical dimension of barrel 32because the respective arms are crossed over one another. By graspingproximal controls 60, the distal end of suturing instrument 30 is guidedto the operative site through a portal sleeve positioned in the wall ofan anatomical cavity. The portal sleeve can be positioned in theanatomical cavity wall using any suitable penetrating technique,including those creating puncture sites by means of removableobturators, such as trocars, and can include a valve housing, ifdesired, to prevent loss of pneumoperitoneum during insertion andwithdrawal of the instrument. Further, retractable sheath 57, which isillustrated in phantom in FIG. 3A, (or another appropriate device) canbe provided to facilitate insertion through a portal sleeve valve byprotecting driver 50 and driver 40. Visualization of the endoscopicprocedure can be accomplished using a conventional endoscopeincorporated into operating channel 38a, for example (known as a singlepuncture procedure) or separately positioned within the anatomicalcavity through a second portal sleeve located at another puncture site(known as a double puncture procedure).

Prior to insertion, buttons 66 and 66' are pushed to the positionillustrated in FIG. 7 to permit the orientation of the handle sets to beadjusted as desired. After adjustment, buttons 66 and 66' are releasedand handles 62 and 64 are set in a desired relative position by thesurgeon so that jaw members 50A and 50B of driver 40 are in the desiredposition. Lock protrusions 63 and 65 can maintain handles 62 and 64 inthe closed or partially closed state to permit an object to be securelyheld while freeing the surgeon's hands for other manipulation.

At any point during the operative procedure, channel 38c can be used forirrigation or aspiration, can serve as a space for holding suturematerial, a needle, clips or the like or can be used as a portal for theintroduction of other medical instruments such as, forceps, cuttingmembers, ligators, or cautery devices. Also, channels 38b and 38d can beused for irrigation, aspiration, insertion of an instrument or the likeby utilizing the passage through inner member 44/44' of driver 40 and/ordriver 50. Tissue can be manipulated, cut, or the like, by manipulatinghandles 62, 64, 62', and 64' as well as knobs 48 and 48' in the desiredmanner. Also, barrel 32 can be rotated to move the end effectors

From the above, it will be appreciated that the instrument according tothe present invention permits manipulation of anatomical tissue duringendoscopic procedures without the need for multiple instruments insertedthrough multiple puncture sites. Driver 40 and driver 50 each areoperable to move an end effector to manipulate or operate on anatomicaltissue positioned proximate driver 40 and driver 50, and can be movedthrough a large working span. While the end effectors described aboveare forceps jaws, it will be understood that any end effectors can beused. Also, any end effectors, including the forceps jaws, can be usedas a cautery electrode by coupling an electrical power source to the endeffector through electrical connector 67, 67' or 81 (which isillustrated in phantom).

A surgical instrument according to a second preferred embodiment isillustrated at 30 in FIGS. 9 and 10. The second preferred embodimentincludes driver 40 and driver 50 and is similar to the first preferredembodiment except for the configuration of arms 51A, 51B, 51A' and 51B'which are curved. Jaw members 50A, 50B and 50A' and 50B' are moveablymounted on a distal end of a respective arm to open and close in amanner similar to the jaws described above.

As is best illustrated in FIG. 9, the arms can easily be confined withinthe diametrical dimension of barrel 32 during insertion. During aprocedure the arms can be moved, by rotating knobs 48 and 48' to causethe jaw members, or any other appropriate end effector, to be movedthrough a path that is outside of the diametrical dimension of barrel32. This embodiment can be used to manipulate tissue in a manner similarto the first embodiment. However, the insertion position of thisembodiment, in which the arms and jaw members are contained within thediametrical dimension of tubular member, does not require that the armscross one another. Therefore, the arms need not be disposed in differentplanes. The jaw members and shafts of this embodiment can be manipulatedin the same way as the first embodiment.

FIGS. 11A and 11B illustrate a third preferred embodiment. Shafts ofdriver 40 and driver 50 of the third preferred embodiment are offsetfrom one another in both the horizontal and vertical direction as viewedin FIGS. 11A and 11B. Also, operating channel 38a is provided in barrel32. In other respects, the third embodiment is similar to the firstembodiment. FIGS. 12A and 12B illustrate a fourth embodiment that issimilar to the third embodiment. However, the fourth embodiment isadopted for "single puncture" procedures. Specifically, operatingchannels 38a-e are defined in barrel 36. Shafts of drivers 40 and 50 aredisposed in operating channels 38b and 38d respectively. Operatingchannels 38a, c, and e can be used for an optical endoscope forvisualization and other instruments, such as a clip applicator orforceps, if necessary. Optical fibers 39 are dispersed throughout barrel32 to direct light from a proximal light source into the body cavity.

A fifth embodiment is illustrated in FIGS. 13A and 13B. In the fifthembodiment, the shafts of both drivers 40 and 50 are disposed in anupper half of barrel 32 as viewed in FIGS. 13A and 13B. Operatingchannels 38a and 38c are provided for the insertion of instruments orfor irrigation or aspiration. The sixth embodiment illustrated in FIGS.14A and 14B is similar to the fifth embodiment. However, in the sixthembodiment, an optical endoscope is disposed in operating channel 38afor viewing, operating channels 38c and 38e can accommodate instruments,such as a clip applicator or forceps, and light transmitting fibers 39are provided for lighting the cavity. Alternatively fiber bundles 39',illustrated as dotted lines, can be provided instead of fibers 39dispersed throughout the cross-sectional area of barrel 32.

In the seventh embodiment illustrated in FIGS. 15A and 15B the arm ofdriver 50 is curved and additional operating channels 38a and c areprovided. In the eighth embodiment illustrated in FIGS. 16A and 16B, anoptical endoscope is disposed in operating channel 38e and eitherdistributed light fibers 39 or fiber bundles 39' are used fortransmitting light.

FIGS. 17A and 17B illustrate a ninth embodiment in which the arms ofboth driver 40 and driver 50 are curved and operating channel 38a iscentralized for insertion of an instrument, for suction, aspiration, orthe like. The tenth embodiment illustrated in FIGS. 18A and 18B issimilar to the ninth embodiment but has optical endoscope in operatingchannel 38a for viewing and fiber bundles 39' for providing light. Ofcourse this embodiment could have light fibers dispersed throughout thecross-sectional area of barrel 32 instead of fiber bundles 39'.

FIGS. 19A and 19B illustrate an eleventh embodiment with curved arms andoperating channels 38a and 38c that are covered by the arms when driver40 and driver 50 are in the insertion, or parked, position illustratedin FIG. 19A. Centralized operating channel 38e is also provided. Thetwelfth embodiment illustrated in FIGS. 20A and 20B includes an opticalendoscope in centralized operating channel 38e and light fibers 39 orfiber bundles 39'.

Any appropriate proximal controls, such as those disclosed above, can beused with the invention depending on the surgeon's preference andexperience. FIG. 21 shows a modification of the proximal controls.Handle 100 is pivotally mounted to barrel 32 and can be locked in anydesired position to facilitate manipulation, such as in the pistol gripposition illustrated in phantom. U shaped handle 110, having ratchetinglock device 112, extends through a slot formed in barrel 32 and has oneleg coupled to inner member 44 and one leg coupled to outer member 42.Compressing handle 110 thus moves outer member 42 distally with respectto inner member 44 to lock operate the end effector of driver 40.U-shaped handle 120, having ratcheting device 122, is coupled to driver50 in a similar manner. Sliding handles 110 and 120 along respectiveslots 111 and 121 causes drivers 40 and 50 to move respectively in theproximal or distal direction. Sliding knob 330 is provided to permitmovement of driver 40 and driver 50 in concert in the proximal and thedistal directions. Knobs 48 and 48' can be rotated to rotate driver 40and 50 respectively. Proximal apertures 90, 91, 92 and 93 are providedfor the insertion of instruments into operating channels.

FIG. 22 illustrates modified proximal controls 60 in which one set ofhandles 62 and 64 are selectively coupled to driver 40 or driver 50 foroperating end effectors. Push button 66 is used to select either driver40 or driver 50. Knobs 48 and 48' having locking push buttons 61, and 63respectively are coupled to shafts of driver 40 and driver 50 to permitrotation and linear movement of driver 40 and apparatus 50.

FIGS. 23 and 24 illustrate the internal mechanism of the proximalcontrols illustrated in FIG. 22. Push button 66 is coupled to shaft 68having gears 69 and 69' fixedly disposed thereon. In the positionillustrated in FIG. 24, gear 69' is engaged with sleeve 55' of driver50. Sleeve 55' is rotatably supported on outer member 42' of driver 55'by flanges 46'. Handles 62 and 64 are coupled to shaft 68 to rotateshaft 68 when handles 62 and 64 are pressed together, thus causingrelative movement between inner member 42' and outer member 44' tooperate an end effector of driver 50. Depression of push button 66slides shaft 68 and causes gear 69 to engage with sleeve 55 of driver40, as illustrated in FIG. 23, to operate an end effector of driver 40in a similar manner. FIG. 24 also illustrates gears 71 and 71' that arerespectively mounted on shafts of driver 40 and driver 50. Gears 71 and71' can slide along the shafts but cannot turn with respect to theshafts because of keys 73 and 73' formed on the shafts and engaged in akeyway of the respective gears. Gears 71 and 71' are engagedrespectively with teeth formed on inner surfaces of knobs 48 and 48'.Therefore, turning knobs 48 and 48' turns respectively the shafts ofneedle driver 40 and needle driver 50. This same turning mechanism canbe used for the proximal controls illustrated in FIGS. 1 and 6. Also,the proximal control of FIGS. 22-24 can have variable orientationhandles similar to those illustrated in FIGS. 1 and 6. Further, shaft 68can be set to positions for disengaging both end effectors or forsimultaneously operating both end effectors. Electrical connectors 67and 81 are provided for unipolar or bipolar cauterization.

Each of the preferred embodiments discussed above have two driver.However, the invention can include any appropriate number of driver formanipulating tissue or performing other procedures. FIG. 25 illustratesa thirteenth preferred embodiment having four driver. Specifically,driver 40, driver 140, driver, driver 50, and driver 150 are eachrotatably mounted in an operating channel defined in barrel 32. Arms ofthe driver lie in different planes to permit the driver to be placed inan insertion position similar to the embodiments discussed above. Theoperating position illustrated permits tissue to be manipulated or otherprocedures to be accomplished. Of course, this embodiment can utilizeany type of end effectors, as needed for the desired procedure. Thethirteenth embodiment is particularly suited to dual electrodecauterization, clamping tissue between adjacent end effectors, orseparating tissue by placing adjacent end effectors between tissuesections and moving the end effectors away from one another. Adjacentend effectors, acting as electrodes, can be pressed against opposingsides of tissue to cauterize the tissue. The polarity of each electrodecan be changed to permit any two electrodes to be used in combination.An optical endoscope can be incorporated into central channel 38f. Also,additional channels can be provides as needed. Of course, thisembodiment can utilize optical fibers or fiber bundles for transmittinglight similar to the other embodiments. Other aspects of this embodimentare similar to the previous embodiments.

In each of the embodiments discussed above, two opposed jaws aremoveable toward one another. However, one of the jaw members can befixed and the other jaw member can be moveable. The driver can be madeof flexible or shape memory materials and can be drawn entirely into thebarrel as disclosed in applicant's copending application entitled"Surgical Instrument with Rotatably Mounted Offset End Effector andMethod of Using the Same", the disclosure of which is incorporatedherein by reference.

FIG. 26 illustrates an alternative driver 40 in which arm member 51A iscoupled to inner member 44 and arm member 51B is coupled to outer member42. Relative rotation between inner member 44 and outer member 42 causejaws 50A and 50B to open/close. Rotation in concert causes the endeffector 50 move. Also, longitudinal and transverse grooves are formedin the jaws to facilitate grasping of a needle or the like.

The two or more driver, can be of the same design or of differentdesigns. For example, one can have forceps jaws as an end effector andone can have a clip applicator as an end effector. Therefore, theinvention can be used for pickup and cutting, pickup and clipping,pickup and suture, or lysis of adhesion procedures. Also, any type ofend effector can be used as a cautery electrode by being coupled to aproximal electric power source through electrical connector 67 (see FIG.1A). Also, a button can be provided to selectively switch the electricpower between end effectors for unipolar cauterization. For example,button 66 can be used.

The jaw closing mechanism of the driver shown and described herein aremerely exemplary of the types of mechanisms that can be used accordingto the present invention. For example, the jaw members can pivot orslide relative to one another as disclosed in the related applicationsnoted above and incorporated herein by reference. The jaw members canalso carry cutting members, such as slots with sharp edges or protrudingblades, and can have opposed arcuate or concave portions for clampingtubular objects, such as organs, without compressing the objects. Also,only one, or more than two driver can be provided. The mechanisms formoving the driver relative to one another and for operating endeffectors are merely exemplary of the types of mechanisms that can beused to perform these functions and other mechanisms can be used.

Operation of the end effectors can be automatically controlled merely bysqueezing the handles together as disclosed in the related applicationsincorporated herein by reference. For example, the handle can be coupledto one or more end effectors to accomplish a desired procedure merely bysqueezing and releasing the handles. Squeezing the handles can performpickup and cutting, pickup and clipping, pickup and stapling, lysis ofadhesion, or any other desired procedure or combination of procedures.

The components of the surgical instrument of the present invention canbe made of any suitable, medical grade materials to permit sterilizationfor reuse or disposal for single patient use. The components can be madeof multiple parts of various configurations and materials to reducecost. The invention can have various valves, stop-cocks and sealstherein to control the flow of fluid and medical devices through thesuturing instrument.

In as much as the present invention is subject to many variations,modifications and changes in detail, it is intended that all subjectmatter discussed above or shown in the accompanying drawings beinterpreted as illustrative only and not be construed as limiting thescope of the invention which is defined by the appended claims.

What is claimed is:
 1. An instrument for manipulating anatomical tissuecomprising:an elongated barrel having a distal end and a proximal end; ahandle coupled to said proximal end of said barrel; a first connectingmember coupled to a distal end of said barrel; a first end effectorextending from said first connecting member, said first end effectorhaving at least two relatively movable members operable by said handleand a longitudinal axis that is offset from a longitudinal axis of saidbarrel; a second connecting member coupled to said distal end of saidbarrel; a second end effector extending from said second connectingmember, said second end effector having at least two relatively movablemembers operable by said handle and a longitudinal axis that is offsetfrom a longitudinal axis of said barrel; wherein said first connectingmember is rotatably coupled to said barrel to rotate about a first axiswithin said barrel between a first position, in which said first endeffector is contained entirely within a diametrical dimension of saidbarrel, and a second position, in which at least a portion of said firstend effector extends beyond the diametrical dimension of said barrel,said first end effector being offset from said first axis.
 2. Aninstrument as recited in claim 1, wherein said second connecting memberis rotatably coupled to said barrel to rotate about a second axis withinsaid barrel between a first position, in which said second end effectoris contained entirely within the diametrical dimension of said barrel,and a second position, which at least a portion of said second endeffector extends beyond the diametrical dimension of said barrel, saidsecond end effector being offset from said second axis.
 3. An instrumentas recited in claim 2, wherein said first connecting member is coupledto a first shaft extending at least partially through said barrel andsaid second connecting member is coupled to a second shaft extending atleast partially through said barrel, said first shaft and said secondshaft being mounted in said barrel to rotate about axes that aresubstantially parallel to the longitudinal axis of said barrel.
 4. Aninstrument as recited in claim 3, further comprising:a first operatingchannel defined in said first shaft and extending from said proximal endto said distal end.
 5. An instrument as recited in claim 4, furthercomprising:a second operating channel defined in said second shaft andextending from said proximal end to said distal end.
 6. An instrument asrecited in claim 3, further comprising a second operating channeldefined in said second shaft and extending from said proximal end tosaid distal end.
 7. An instrument as recited in claim 2, wherein saidfirst connecting member extends from a distal end of said barrel in adirection that is substantially perpendicular to an axis of said barreland said second connecting member extends from a distal end of saidbarrel in a direction that is substantially perpendicular to an axis ofsaid barrel.
 8. An instrument as recited in claim 7, wherein said firstconnecting member comprises a pair of first arm members and said secondconnecting member comprises a pair of second arm members.
 9. Aninstrument as recited in claim 7, wherein said second connecting memberis in a plane which is different than that of said first connectingmember.
 10. An instrument as recited in claim 7, wherein the firstconnecting member is arcuate.
 11. An instrument as recited in claim 10,wherein said second connecting member is arcuate.
 12. An instrument foreffecting procedures on anatomical tissue comprising:an elongated barrelhaving a distal end and a proximal end; a handle coupled to saidproximal end of said barrel; a first connecting member coupled to adistal end of said barrel and extending transversely from said barrel; afirst end effector having two relatively movable members operable bysaid handle and extending from said first connecting member; a secondconnecting member coupled to a distal end of said barrel and extendingtransversely from said barrel; and a second end effector having tworelatively movable members operable by said handle and extending fromsaid second connecting member; wherein said first connecting member isrotatably coupled to said barrel to rotate about an axis within saidbarrel between a first position, in which said first end effector iscontained entirely within a diametrical dimension of said barrel, and asecond position, in which at least a portion of said first end effectorextends beyond the diametrical dimension of said barrel.
 13. Aninstrument as recited in claim 12, wherein said second connecting memberis rotatably coupled to said barrel to rotate about an axis within saidbarrel between a first position, in which said second end effector iscontained entirely within the diametrical dimension of said barrel, anda second position, in which at least a portion of said second endeffector extends beyond the diametrical dimension of said barrel.
 14. Aninstrument as recited in claim 13, wherein said first connecting memberis coupled to a first shaft extending at least partially through saidbarrel and said second connecting member is coupled to a second shaftextending at least partially through said barrel said first shaft andsaid second shaft being mounted in said barrel to rotate about axes thatare substantially parallel to the longitudinal axis of said barrel. 15.An instrument as recited in claim 14, wherein said second connectingmember is in a plane which is different than that of said firstconnecting member.
 16. An instrument as recited in claim 14, furthercomprising a first operating channel defined in said first shaft andextending from said proximal end to said distal end.
 17. An instrumentas recited in claim 16, further comprising a second operating channeldefined in said second shaft and extending from said proximal end tosaid distal end.
 18. An instrument as recited in claim 14 furthercomprising a second operating channel defined in said second shaft andextending from said proximal end to said distal end.
 19. An instrumentfor effecting procedures on anatomical tissue comprising:an elongatedhollow barrel having a distal end and a proximal end; a first shaftextending through at least a portion of said barrel; a first pair of armmembers disposed on a distal end of said first shaft and extending fromthe distal end of said first shaft in a direction that is substantiallyperpendicular to an axis of rotation of said first shaft; a first endeffector extending from said first pair of arm members, said first endeffector having a longitudinal axis that is offset from a longitudinalaxis of said first shaft; a second shaft extending through at least aportion of said barrel; a second pair of arm members disposed on adistal end of said second shaft and extending from a distal end of saidsecond shaft in a direction that is substantially perpendicular to anaxis of rotation of said second shaft; and a second end effectorextending from said second pair of arm members, said second end effectorhaving a longitudinal axis that is offset from a longitudinal axis ofsaid second shaft; wherein said first shaft is rotatably mounted in saidbarrel to rotate about an axis substantially parallel to thelongitudinal axis of said barrel to move said first pair of arm membersbetween a first position, in which said first end effector is containedentirely within a diametrical dimension of said barrel, and a secondposition, in which at least a portion of said first end effector extendsbeyond the diametrical dimension of said barrel, and said second shaftis rotatably mounted in said barrel to rotate about an axissubstantially parallel to the longitudinal axis of said barrel to movesaid second pair of arm members between a first position, in which saidsecond end effector is contained entirely within the diametricaldimension of said barrel, and a second position, in which at least aportion of said second end effector extends beyond the diametricaldimension of said barrel.
 20. An instrument for effecting procedures onanatomical tissue comprising:an elongated hollow barrel having a distalend and a proximal end; a first shaft having a longitudinal axis andextending through at least a portion of said barrel; a first connectingmember extending from a distal end of said first shaft in a directionperpendicular to the longitudinal axis of said first shaft; a first endeffector extending from said first connecting member, said first endeffector having a longitudinal axis that is offset from a longitudinalaxis of said first shaft; a second shaft having a longitudinal axis andextending through at least a portion of said barrel; a second connectingmember extending from a distal end of said second shaft in a directionperpendicular to the longitudinal axis of said second shaft; and asecond end effector extending from said second connecting member, saidsecond end effector having a longitudinal axis that is offset from alongitudinal axis of said second shaft; wherein said first shaft isrotatably mounted in said barrel to move said first connecting memberbetween a first position, in which said first end effector is containedentirely within a diametrical dimension of said barrel, and a secondposition, in which at least a portion of said first end effector extendsbeyond the diametrical dimension of said barrel and said second shaft isrotatably mounted in said barrel to move said second connecting memberbetween a first position, in which said second end effector is containedentirely within a diametrical dimension of said barrel, and a secondposition, in which at least a portion of said second end effectorextends beyond the diametrical dimension of said barrel.
 21. Anapparatus as recited in claim 20, wherein said first connecting memberincludes a pair of first arm members and said second connecting memberincludes a pair of second arm members.
 22. An apparatus as recited inclaim 20, wherein said second connecting member is in a plane which isdifferent than that of said first connecting member.
 23. An apparatus asrecited in claim 20, wherein said first connecting member is arcuate.24. An apparatus as recited in claim 20, wherein said second connectingmember is arcuate.
 25. An instrument for effecting procedures onanatomical tissue comprising:an elongated barrel having a distal end anda proximal end; a first shaft extending through at least a portion ofsaid barrel; a first pair of arm members disposed on a distal end ofsaid first shaft; a first end effector extending from said first pair ofarm members, said first end effector having a longitudinal axis that isoffset from a longitudinal axis of said first shaft; a second shaftextending through at least a portion of said barrel; a second pair ofarm members disposed on a distal end of said second shaft; and a secondend effector extending from said second pair of arm members, said secondend effector having a longitudinal axis that is offset from alongitudinal axis of said second shaft; wherein said first shaft isrotatably mounted in said barrel to rotate about an axis substantiallyparallel to the longitudinal axis of said barrel to move said first pairof arm members between a first position, in which said first endeffector is contained entirely within a diametrical dimension of saidbarrel, and a second position, in which at least a portion of said firstend effector extends beyond the diametrical dimension of said barrel,and said second shaft is rotatably mounted in said barrel to rotateabout an axis substantially parallel to the longitudinal axis of saidbarrel to move said second pair of arm members between a first position,in which said second end effector is contained entirely within thediametrical dimension of said barrel, and a second position, in which atleast a portion of said second end effector extends beyond thediametrical dimension of said barrel.
 26. An instrument for effectingprocedures on anatomical tissue comprising:an elongated barrel; a firstshaft extending through at least a portion of said barrel; a firstconnecting member disposed on a distal end of said first shaft; a firstend effector extending from said first connecting member, said first endeffector having a longitudinal axis that is offset from a longitudinalaxis of said first shaft; a second shaft extending through at least aportion of said barrel; a second connecting member disposed on a distalend of said second shaft; and a second end effector extending from saidsecond connecting member, said second end effector having a longitudinalaxis that is offset from a longitudinal axis of said second shaft;wherein said first shaft is rotatably mounted in said barrel to movesaid first connecting member between a first position, in which saidfirst end effector is contained entirely within a diametrical dimensionof said barrel, and a second position, in which at least a portion ofsaid first end effector extends beyond the diametrical dimension of saidbarrel and wherein a first operating channel is defined through saidfirst shaft.
 27. An instrument as recited in claim 26, wherein saidsecond shaft is rotatably mounted in said barrel to move said secondconnecting member between a first position, in which said second endeffector is contained entirely within the diametrical dimension of saidbarrel, and a second position, in which at least a portion of saidsecond end effector extends beyond the diametrical dimension of saidbarrel.
 28. An instrument as recited in claim 27, wherein said firstconnecting member extends from a distal end of said first shaft in adirection that is substantially perpendicular to an axis of rotation ofsaid first shaft and said second connecting member extends from a distalend of said second shaft in a direction that is substantiallyperpendicular to an axis of rotation of said second shaft.
 29. Aninstrument as recited in claim 28, wherein said first connecting memberincludes a pair of first arm members and said second connecting memberincludes a pair of second arm members.
 30. An instrument as recited inclaim 28, wherein said second connecting member is in a plane which isdifferent than that of said first connecting member.
 31. An instrumentas recited in claim 26, further comprising a second operating channeldefined in said second shaft and extending from said proximal end tosaid distal end.
 32. An instrument for effecting procedures onanatomical tissue comprising:an elongated barrel; a first shaftextending through at least a portion of said barrel; an arcuate firstconnecting member disposed on a distal end of said first shaft; a firstend effector extending from said first connecting member, said first endeffector having a longitudinal axis that is offset from a longitudinalaxis of said first shaft; a second shaft extending through at least aportion of said barrel; an arcuate second connecting member disposed ona distal end of said second shaft; a second end effector extending fromsaid second connecting member, said second end effector having alongitudinal axis that is offset from a longitudinal axis of said secondshaft; and wherein said first shaft is rotatably mounted in said barrelto move said first connecting member between a first position, in whichsaid first end effector is contained entirely within a diametricaldimension of said barrel, and a second position, in which at least aportion of said first end effector extends beyond the diametricaldimension of said barrel.
 33. An instrument for effecting procedures onanatomical tissue comprising:an elongated hollow barrel having a distalend and a proximal end; a first shaft having a longitudinal axis andextending through at least a portion of said barrel; a first connectingmember extending transversely from a distal end of said first shaft; afirst end effector extending from said first connecting member, saidfirst end effector having a longitudinal axis that is offset from alongitudinal axis of said first shaft; a second shaft having alongitudinal axis and extending through at least a portion of saidbarrel; a second connecting member extending transversely from a distalend of said second shaft; a second end effector extending from saidsecond connecting member, said second end effector having a longitudinalaxis that is offset from a longitudinal axis of said second shaft; andwherein said first shaft is rotatably mounted in said barrel to movesaid first connecting member through a first path and said second shaftis rotatably mounted in said barrel to move said second connectingmember through a second path that does not intersect said first path tothereby permit said first connecting member and said second connectingmember to be crossed over one another without interfering with oneanother.
 34. An instrument as recited in claim 33, wherein said firstconnecting member extends perpendicularly from said first shaft and saidsecond connecting member extends perpendicularly from said second shaft.